近端为主胃癌的根治性术式选择

Selection of radical operative modalities for proximal gastric cancer

目的探讨近端为主胃癌的根治性术式选择依据。方法回顾性分析中山大学胃癌诊治中心自1994年8月至2010年12月近端为主胃癌366例，依手术方式分为根治性近端胃切除组（PG组，77例）和根治性全胃切除组（TG组，289例），比较两组患者的临床病理特征、手术情况、术后并发症及生存质量、预后等，进而阐述其术式选择依据。结果两组患者性别、年龄、癌胚抗原（CEA）值差异均无统计学意义（均P〉0．05）。PG组肿瘤35cm、脏器侵犯、淋巴结转移、远处转移、浸润癌、低分化癌比例均低于TG组[15．6％（12／77）比49．8％（144／289）、16．9％（13／77）比37．7％（109／289）、67．5％（52／77）比79．9％（231／289）、3．9％（3／77）比11．4％（33／289）、45．5％（35／77）比68．9％（199／289）、32．5％（25／77）比57．8％（167／289），均P〈0．05]。PG组手术时间、中位输血量、淋巴结清扫总数、淋巴结阳性中位数、联合脏器切除率均低于TG组[（256±83）比（298±86）min、0比400ml、（15±12）比（26±15）枚、0比3（枚）、15．6％（12／77）比43．2％（125／289），均P〈0．05]，而并发症发生率高于TG组[14．3％（11／77）比7．6％（22／289），P〈0．05]。两组患者术后生活质量差异均无统计学意义（均P〉0．05）。肿瘤〈5cm、无脏器侵犯、无淋巴结转移、无远处转移时两组生存期差异均无统计学意义（均P〉0．05）。肿瘤35am、合并脏器侵犯、淋巴结转移、远处转移时PG组的中位生存期均短于TG组（月：15．0比29．0、15．0比30．0、34．0比45．0、4．0比18．0，均P〈0．05）。结论对合并脏器侵犯、淋巴结转移、远处转移、肿瘤≥5c的近端癌行根治性全胃切除较近端胃切除能显著改善预后。

Objective To evaluate the rationality of different radical operative modalities forproximal gastric cancer. Methods A total of 366 cases of proximal gastric cancer undergoing radical dissection were screened from data base. According to the operative modalities, they were divided into proximal gastrectomy group （PG） （ n = 77 ） and total gastreetomy group （TG） （ n = 289 ）. Through the comparisons of clinical pathologic features, surgical profiles, postoperative complications, postoperative quality-of-life and prognosis in two groups, the rationality of different operative modalities was evaluated. Results No significant differences existed in age, gender or eareinombryonic antigen （CEA） value between two groups （ all P 〉 0. 05 ） . The rates of tumor diameter ≥ 5 cm, organic infiltration, lymph nodes metastasis, distal organs metastasis, infiltrative type, poorly differentiated tumor in PG and TG groups were 15.6% （ 12/77 ） vs 49. 8% （144/289）, 16. 9% （ 13/77 ） vs 37.7% （109/289）, 67.5% （52/77） vs 79. 9% （231/289）, 3.9% （3/77） vs 11.4% （33/289）, 45.5% （35/77） vs 68.9% （ 199/289）, 32. 5% （25/77） vs 57.8% （ 167/289 ） respectively （ all P 〈 0. 05 ）. Operative duration, volume of blood transfusion, number of dissected lymph nodes and positive lymph nodes, rate of combined organic resection and complications in groups of PG and TG were （256 ± 83） vs （298 ± 86） rain, 0 vs 400 ml, 15 ± 12 vs 26±15, 0 vs 3, 15.6% （12/77） vs 43.2% （125/289）, 14. 3% （11/77） vs 7. 6% （22/289） respectively （all P 〈 0. 05 ）. In two groups, the evaluating indices of posteroperative quality-of-life showed no significant differences （ P 〉 0. 05 ）. In two groups, the median survival time of the cases with tumor diameter 〈 5 cm, no-organic infiltration, no-peri-tumor lymph nodes metastasis, no-distal organic metastasis had no significant difference （all P 〉 0. 05）. However, in groups of PG and TG, the median survival time of the cases with tumor diameter ≥5 cm, organic infiltration, peri-tumor lymph nodes metastasis and distal organic metastasis was 15.0 months vs 29. 0 months, 15.0 months vs 30. 0 months, 34. 0 months vs 45.0 months, 4.0 months vs 18.0 months respectively（ all P 〈 0. 05）. Conclusion As compared with radical proximal gastrectomy, radical total gastrectomy improves significantly the prognosis of patients of proximal gastric cancer with organic infiltration, peri-tumor lymph nodes metastasis, distal organic metastasis and tumor diameter≥5 cm.